Neck Pain Care Pathway

Date of last update: August, 2024

9. Treatment Considerations for Neck Pain Amenable to Conservative Care

(Common neck pain, neck pain with radicular pain/radiculopathy from disc pathology and WAD III)

Report of Findings (ROF) and Informed Consent

The Report of Findings (ROF) and Informed Consent process is crucial to patient care and to the therapeutic relationship. It involves explaining the diagnosis, prognosis, and treatment plan to the patient. This ensures the patient understands their condition and the proposed management strategies and agrees to the treatment plan voluntarily. Consider the following opportunities to develop a shared understanding:

1. Review of Diagnosis and Prognosis:

Clearly explain the diagnosis, results of examinations and tests, and the expected course of the condition using understandable language and visual aids if necessary.

2. Treatment Plan Overview:

Discuss the recommended treatments and their rationale.
Explain how each intervention aligns with the patient's goals and preferences.

3. Informed Consent:

Explain the condition: Use clear and simple language to describe the patient's condition and how it affects their health.
Discuss treatment options: Provide detailed information about each treatment option, including the potential benefits, risks, and alternatives.
Address questions and concerns:
1. Encourage the patient to ask questions and discuss any concerns they may have.
2. Provide thorough and understandable answers to ensure the patient feels comfortable and informed.
Obtain explicit consent:
1. Review the diagnosis.
2. Propose a plan of care that relates to the patient’s condition and circumstances.
3. Contextualize the potential risks and benefits of the proposed treatments.
4. Encourage the patient to ask questions or express any concerns they may have. Consider utilizing strategies such as “teach-back” to confirm patient understanding.
5. Ensure that all questions and concerns are appropriately addressed before proceeding.
6. Obtain explicit consent from the patient to proceed with the proposed treatment plan.
Document the consent: Ensure the patient's consent is documented in their clinical record. Concisely record the information provided, questions asked by the patient, and the patient's understanding and agreement to the treatment plan.
Adhere to jurisdictional standards: Ensure the practitioner is meeting their jurisdiction’s standards of practice for informed consent.

Essential Interventions:

Essential for managing neck pain and applicable to all patients, focusing on optimizing function and participation in daily life.

Education and Reassurance:

Rationale: Helps patients understand their condition, implement pain management strategies, and actively participate in the rehabilitation process.
Advantages: Increases patient confidence and engagement in their care.
Disadvantages: Requires time and effective communication skills.
Key Points:
- Most acute neck pain episodes improve within weeks; clarify pain's biopsychosocial dimensions and set realistic expectations.
- There is limited evidence of superior education types for improving patient outcomes. Tailor education strategies (e.g., general neck pain, pain neurophysiology) to individual patient needs and preferences (e.g., written, digital, visual).
- While passive modalities such as Transcutaneous Electrical Nerve Stimulation (TENS), needling therapies (acupuncture, dry needling), and traction might offer pain relief or relaxation, it is essential to integrate these with active management strategies. This combination addresses the multifaceted nature of neck pain, fostering sustainable pain management and enhancing function and participation.
- Regularly engage patients in the educational process and assess their understanding to ensure effective communication and knowledge retention.

Address Yellow Flags:

Rationale: Factors (fear of movement, anxiety, depression, and social or occupational stressors) can significantly influence the perception of pain, adherence to treatment, and overall recovery.
Advantages: Promotes a more comprehensive approach to treatment, promotes active participation, improves recovery outcomes.
Disadvantages: Requires time and resources; some people may resist addressing psychosocial factors; may require a multidisciplinary approach.
Key Points:
- Screen for psychosocial factors using validated tools, such as the Fear-Avoidance Beliefs Questionnaire (FABQ), Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7), Opioid Risk Tool (ORT), or the Pain Catastrophizing Scale (PCS).
- Educate patients on how these factors influence their pain and recovery, and incorporate cognitive behavioral techniques (CBT) to help them manage fear, anxiety, and negative thoughts.
- Refer to mental health professionals when necessary, especially for significant distress or mental health disorders. Collaborate with other healthcare providers for an integrated, multidisciplinary approach.
- Encourage support from family, friends, and support groups, and maintain open, empathetic communication to regularly discuss concerns and progress.

Maintain Activities of Daily Living:

Rationale: Prevents deconditioning and promotes recovery.
Advantages: Maintains function and reduces disability.
Disadvantages: Patients may need guidance on safe activities.
Key Points: Encourage normal activities and proper self-care. Use Brief Action Planning for self-management.

Self-Care:

Rationale: Supports long-term health.
Advantages: Empowers patients.
Disadvantages: May require continuous motivation and support.
Key Points:
- Set SMART goals, prioritize a healthy diet, regular physical activity, good sleep habits, stress management, and avoid smoking/substance abuse.
- Implement ergonomics and behavior changes to reduce strain.
- Utilize techniques like Brief Action Planning to support self-management and promote regular movement and engagement in normal activities, including work.

Engage in Social and Work Activities:

Rationale: Promotes well-being and independence.
Advantages: Enhances mental health and maintains conditioning.
Disadvantages: May be challenging for severe pain cases, risk of symptom exacerbation, requires balanced activity.
Key Points:
- Encourage gradual re-engagement.
- Modify activities to fit current functional levels.
- Educate on pacing and support workplace accommodations/modifications if needed.

Optional Interventions: Tailored to patient needs and preferences through shared decision-making (SDM). These interventions have varying evidence levels.

Exercise Therapy:

Rationale: Enhances strength, flexibility, and fitness.
Advantages: Improves function and reduces pain.
Disadvantages: Requires regular commitment and proper technique.
Key Points:
- Types of exercises: Includes strengthening, range of motion, aerobic, mind-body exercises (e.g., yoga, tai chi). There is limited evidence of superior exercise types for improving patient outcomes. Tailor to individual needs and preferences.
- Psychological considerations: Challenging patients during exercise therapy (beyond psychotherapy) can have psychological implications. Watch for signs of increased anxiety, depression, or distress related to the exercise regimen. Be mindful if the person’s mental health condition worsens despite adherence to the exercise program or if the person expresses a strong aversion or fear of the exercises.
- Referral threshold: Consider referral to the appropriate provider (physician, psychologist, psychiatrist, mental health professional) when the psychological burden of exercise therapy exceeds the patient’s coping capacity or falls outside of the scope (e.g., person exhibits significant psychological barriers or disorders such as severe anxiety or depression).

Manual Therapy:

Rationale: Provides symptom relief and improves mobility.
Advantages: Immediate pain relief.
Disadvantages: Effects may be temporary; requires skilled practitioners.
Key Points: Techniques include mobilization, manipulation, soft tissue techniques, and massage. Adjust based on pain exacerbation. Contraindications to spinal manipulation therapy include:

Absolute Contraindications

Relative Contraindications

Region-specific Contraindications

- Acute fracture
- Acute infection (osteomyelitis, septic discitis, tuberculosis of the spine)
- Aggressive benign tumors (aneurismal bone cyst, giant cell tumor, osteoblastoma, osteoid osteoma)
- Anomalies such as dens hypoplasia,
unstable os odontoideum
- Arnold Chiari malformation
- Basilar invagination of the upper cervical spine
- Congenital generalized hypermobility
- Diastematomyelia
- Dislocation of a vertebra
- Frank disc herniation with progressive neurological deficit
- Hematomas (spinal cord or intracanalicular)
- Hydrocephalus of unknown etiology
- Internal fixation/stabilization devices
- Malignancy of the spine
- Meningeal tumor
- Neoplastic disease of muscle or soft tissue
- Positive Kernig’s or L’hermitte’s signs
- Signs or patterns of instability
- Spinal cord tumor
- Syringomyelia

- Articular hypermobility and uncertain joint stability
- Acute injuries of joints and soft tissues
- Benign bone tumors with risk of pathological
- Bone weakened by metabolic disorders
- Circulatory and hematological disorders
- Demineralization of bone (osteoporosis, long-term steroid therapy)
fractures
- Infection of bone and joint
- Malignancies, including malignant bone tumors
- Neurological disorders
- Postsurgical joints or segments with no evidence of instability
- Severe or painful disc pathology (discitis, disc herniations)
- Traumatic events requiring careful examination for excessive motion
- Tumor-like and dysplastic bone lesions

- Aneurysm involving a major blood vessel
- Atlantoaxial instability
- Bleeding disorders (anticoagulant therapy, blood dyscrasias)
- Vertebrobasilar insufficiency syndrome

Medications:

Rationale: Includes alleviating pain and inflammation.
Advantages: Quick relief.
Disadvantages: Potential side effects and risk of dependency.
Key Points: Includes over the counter (OTC) pain relievers, muscle relaxants, NSAIDs. Use judiciously and combine with other treatments. If OTC/prescribed medication is out of practice scope for practitioners (e.g., chiropractors, physiotherapists) refer to the appropriate provider (e.g., medical physician, nurse practitioner, pharmacist).

Psychological Support:

Rationale: Addresses emotional and cognitive aspects of pain.
Advantages: Reduces psychological barriers to recovery.
Disadvantages: Requires patient willingness to engage.
Key Points: Techniques like mindfulness, meditation, CBT, counselling.
- Referral Threshold: Referrals should be considered for patients showing significant disorders of thought, mood, or behavior, particularly when: symptoms are severe or persistent; there is no improvement in symptoms despite conservative management; functional impairment significantly impacts the patient’s daily activities and quality of life; there are signs of moderate to severe pathology based on Patient-Reported Outcome Measures (PROMs) thresholds (e.g., PHQ-9, GAD-7); management falls outside the scope of practice, such as the need for specialized psychotherapy or psychiatric intervention.

Social Support:

Rationale: Enhances coping mechanisms through community and family support.
Advantages: Provides emotional and practical support.
Disadvantages: Social dynamics can be complex.
Key Points: Encourages engagement in social and work activities, fostering a supportive environment.
- Referral Threshold: Consider referrals when the person lacks adequate social support, which may impact their recovery; there are significant social or environmental barriers that cannot be addressed within the scope of clinical practice; the patient needs specialized support services, such as social work or community resources.

Mind-Body Interventions:

Rationale: Integrates mental and physical health.
Advantages: Reduces stress and improves well-being.
Disadvantages: Requires patient openness and engagement.
Key Points: Includes practices like mindfulness, meditation, yoga, tai chi.
- Referral Threshold: Consider referral to practitioners who specialize in mind-body therapies (e.g., yoga therapists, meditation instructors, tai chi practitioners) when the person exhibits high levels of stress or anxiety that could benefit from structured mind-body interventions; conservative management alone does not adequately address the patient’s psychological or physical stress symptoms; the person needs specialized instruction or support in engaging with mind-body practices.

Needling Therapies:

Rationale: May provide pain relief.
Advantages: Alternative pain management.
Disadvantages: Mixed evidence; may cause discomfort.
Key Points: Should be considered as supportive to essential interventions.

Topical Cayenne Pepper:

Rationale: May provide pain relief.
Advantages: Non-invasive localized treatment.
Disadvantages: Mixed evidence; may cause skin irritation.
Key Points: Applied as a cream or patch. Use under healthcare provider guidance.

Electrotherapies (e.g., TENS, IFC, low-level laser):

Rationale: May provide temporary relief.
Advantages: Non-invasive.
Disadvantages: Limited evidence on benefits.
Key Points: Should be considered as supportive to essential interventions.

Multicomponent Biopsychosocial Care:

Rationale: Integrates multiple therapeutic approaches.
Advantages: Comprehensive and holistic.
Disadvantages: Requires coordination among multiple healthcare providers, can be resource intensive.
Key Points: Combines therapies such as CBT, manual and exercise therapy, social support. Tailored to patient needs.

Persistent Neck Pain: Functional limitations are more likely with persistent neck pain. Adopting a biopsychosocial approach to assessment and care planning becomes paramount. Rehabilitation aims to sustain independence in daily activities and ensure active participation in vital areas such as work and community life, which are crucial for well-being. It involves a spectrum of non-pharmacologic and pharmacologic interventions, with non-pharmacological options often taking precedence. Rehabilitation thus spans a wide array of services, supports, and community resources, all aimed at enhancing overall well-being and societal involvement.

Examples

Example 1: Common Chronic Neck Pain (Mechanical or Strain/sprain)

Patient Presentation: A patient presents with chronic neck pain persisting for more than 12 weeks, localized below the nuchal line and above the shoulders, with occasional referred pain across the shoulder blades. The pain is sharp and dull, aggravated by prolonged sitting and computer use.

Essential Interventions:

Education and Reassurance:
- Frequency: Initial visit and reinforced in follow-up visits.
- Protocol: Provide a clear explanation of the condition, expected course with treatment (may be 6-12 weeks), and encourage the patient to stay active. Use visual aids or pamphlets for better understanding.
Maintain Activities of Daily Living:
- Frequency: Daily.
- Protocol: Encourage the patient to continue with normal activities as much as possible, avoiding prolonged bed rest. Provide specific instructions on safe movements and ergonomics.
Self-Care Practices:
- Frequency: Daily.
- Protocol: Recommend a home exercise program focused on stretching and strengthening exercises tailored to the patient's abilities and pain levels. Advise on proper nutrition, adequate sleep, and stress management techniques.
Address Yellow Flags (Psychosocial Factors):
- Frequency: Regularly, integrated into each visit.
- Protocol: Identify and address psychosocial factors such as fear of movement, depression, or anxiety. Use cognitive-behavioral strategies to modify negative beliefs about pain.

Optional Interventions:

Manual Therapy:
- Frequency: Six sessions over 8 weeks. A second course may be indicated if the patient demonstrates ongoing and significant improvement according to their goals.
- Protocol: Spinal manipulation/mobilization and soft tissue techniques to relieve pain and improve mobility. Adjust techniques based on the patient's response.
Exercise Therapy:
- Frequency: 3 times per week for up to 20 weeks. Supervised 0-2 times per week for up to 12 weeks.
- Protocol: Include 20-minute sessions of a combination of aerobic exercises (e.g., walking), and strengthening exercises. Sessions may be supervised initially.
Electromodalities (e.g., TENS, IFC, low-level laser):
- Frequency: 2-3 times per week.
- Dose: Utilize Transcutaneous Electrical Nerve Stimulation (TENS), Interferential Current Therapy (IFC), or low-level laser therapy to provide temporary pain relief and comfort. Use in conjunction with other interventions.
Medications:
- Frequency: As needed.
- Protocol: Over-the-counter NSAIDs or acetaminophen for pain relief, used judiciously and in combination with other treatments. Consider muscle relaxants if indicated.
Psychological Support:
- Frequency: Weekly or as needed.
- Protocol: Cognitive-behavioral therapy (CBT), mindfulness-based stress reduction, and other techniques to manage chronic pain and improve mental health.

Follow-Up:

Regular follow-up at each visit. Reassess pain levels, functional status, and goal achievement every 2-4 weeks and adjust the treatment plan as necessary.

Example 2: Neck Pain with Radiculopathy (Disc Protrusion/Herniation)

Patient Presentation: A patient presents with neck pain radiating down the arm, often to the hand, following a specific dermatomal pattern. The pain is sharp and shooting, exacerbated by bending the head forward.

Essential Interventions:

Education and Reassurance:
- Frequency: Initial visit and reinforced in follow-up visits.
- Protocol: Explain the nature of radiculopathy, expected course (may be 4 weeks to 12 weeks), and encourage active participation in the treatment plan. Use visual aids (e.g. diagrams, models, digital resources) to illustrate the condition.
Maintain Activities of Daily Living:
- Frequency: Daily.
- Protocol: Encourage modified activities to avoid exacerbating the symptoms while staying active. Provide guidance on ergonomics and safe movement strategies.
Self-Care Practices:
- Frequency: Daily.
- Protocol: Tailored home exercise program focusing on nerve mobilization exercises, gentle stretching, and strengthening. Include lifestyle advice on proper posture, nutrition, and sleep.
Address Yellow Flags (Psychosocial Factors):
- Frequency: At each visit.
- Protocol: Identify and address factors such as fear of movement, poor recovery expectations, depression, anxiety, work-related or family issues, litigation or compensation claims, and maladaptive coping mechanisms. Provide appropriate reassurance, counseling, or referrals to mental health professionals as needed.

Optional Interventions:

Manual Therapy:
- Frequency: Six sessions over 8 weeks. A second course may be indicated if the patient demonstrates ongoing and significant improvement according to their goals.
- Protocol: Spinal mobilization techniques to alleviate pain and improve function. Techniques should be adjusted based on patient response and pain levels.
Exercise Therapy:
- Frequency: Daily for 6 weeks. Supervised 4 times in the first 6 weeks.
- Protocol: Include specific exercises to relieve nerve tension (e.g., directional exercises), core stabilization, and aerobic conditioning. Begin with supervised sessions and transition to the home program.
Electromodalities (e.g., TENS, IFC, low-level laser):
- Frequency: 2-5 times per week for 3 weeks.
- Protocol: Utilize TENS, IFC, or low-level laser therapy to provide temporary pain relief and comfort. Use as an adjunct to other therapies.
Medications:
- Frequency: As needed.
- Protocol: NSAIDs or acetaminophen for pain management, possibly combined with muscle relaxants for short-term relief of acute symptoms.
Psychological Support:
- Frequency: Weekly or as needed.
- Protocol: Cognitive-behavioral therapy (CBT), mindfulness-based stress reduction, and other techniques to manage chronic pain and improve mental health.

Follow-Up:

Regular follow-up at each visit. Reassess pain levels, functional status, goal achievement every 2-4 weeks and adjust the treatment plan as necessary.

Neck Pain Care Pathway

1. Record Keeping

Document all findings and recommendations on an ongoing basis, including SOAP notes at each visit (subjective, objective, assessment, plan).
Adhere to jurisdictional standards.

2. Informed Consent

Document verbal consent for health history taking, physical examination, contact in sensitive areas.
Obtain written consent for treatment.
Adhere to jurisdictional standards.

3. Health History

Apply cultural awareness and trauma-informed care principles.
Sociodemographic: Age, gender, sex.
Main complaint: Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.
Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, muscles and joints, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
Health, lifestyle, family, social, and occupational history: Past medical conditions, medications (including opioids, oral contraception, etc.), supplements, injuries, hospitalizations, surgeries, diet, exercise, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.
Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.
Previous treatments and responses: Effectiveness and any adverse events.
Beliefs and expectations: Understanding of their condition, treatment expectations.
Red, yellow, and orange flags (sections 4 – 6).

Meaningful Outcomes:

Pain: Pain scales (e.g., NRS), pain diagram.
Function and Participation: Impact of neck pain on daily activities (PSFS, WHODAS, NDI, MYMOP, MYMOP Follow-up).
Recovery: Self-rated recovery scales.
Quality of Life: SF-12.
Work Status: Return to work/school/activities.
Individual Goals: SMART goal setting: Specific, Measurable, Achievable, Relevant, Timely.
Patient Feedback: Experience and satisfaction with care.

4. Differential Diagnosis Requiring Medical Attention

ACTION: Refer to emergency care immediately for red flags:

Cervical Myelopathy: Gait disturbances, hand clumsiness, non-dermatomal numbness, lower extremity numbness or weakness, bowel or bladder dysfunction.
Meningitis: Neck stiffness, severe headache worsening with neck flexion, fever, vomiting, rash, altered mental status, photophobia.
Spinal Infection: Immunosuppression, recent infection or surgery, TB (tuberculosis) history, unexplained constitutional symptoms (e.g., fever/chills), IV drug use, poor living conditions.
Intracranial/Brain Lesion: Sudden intense headache (thunderclap); unexplained headache, dizziness, or visual changes.
Vertebral/Carotid Artery Dissection: Severe neck pain or headache (“worst pain ever”), double vision, difficulty swallowing, facial numbness, difficulty walking, drop attacks, nausea, nystagmus.
Traumatic Spinal Fracture: Age ≥65 years, dangerous mechanism (e.g., pedestrian struck, high-speed motor vehicle collision, rollover, ejection from motor vehicle, fall from elevation ≥3 feet or 5 stairs, axial load to head), extremity weakness/tingling/burning, inability to actively rotate neck 45° left and right, midline cervical spine tenderness (Canadian C-Spine Rule).

ACTION: Refer to appropriate medical provider:

Non-traumatic Spinal Fracture: Sudden severe pain, osteoporosis, corticosteroid use, female sex, age >60, spinal fracture/cancer history.
Spinal Malignancy: Progressive pain, cancer history, constitutional symptoms (e.g., fatigue, weight loss, night pain), progressive headache worse with exertion.
Inflammatory Arthritides (e.g., spondyloarthropathies, rheumatoid arthritis, systemic lupus erythematosus): Morning stiffness >1 hour, systemic symptoms (e.g., fatigue, weight loss, fever), symmetrical joint pain, joint swelling/deformity, skin lesions.

5. Psychiatric Disorders (Orange Flags)

Symptoms of major depression, personality disorders, PTSD, substance addiction and abuse.
Screening tools: PHQ-9, GAD-7.
Action: Refer to appropriate provider/psychiatric specialist.

6. Psychosocial Factors (Yellow Flags)

Factors that may delay recovery: Fear of movement, poor recovery expectations, depression, anxiety, reduced activity, over-reliance on passive treatments, lack of social support, work-related issues, family issues, litigation or compensation claims, maladaptive coping mechanisms.
Screening tools: PHQ-9, GAD-7, FABQ, ORT, PCS.
Action: Address these as part of conservative care, co-manage, or refer to an appropriate provider.

7. Physical Examination

Observation: Abnormalities, asymmetries, posture, balance, gait, movements, facial expression.
Range of Motion: Active, passive, resisted (flexion, extension, lateral flexion, rotation).
Palpation: Bone, joint, and muscle for tenderness, swelling, muscle tightness, or temperature changes.
Neurological Examination: Motor strength, sensory and reflex testing (C5, C6, C7, C8, T1); upper and lower motor neuron signs; cranial nerves screening (including facial numbness; facial movements such as smile, tongue deviation, eye movements).
Special/Orthopedic Tests: Select as appropriate based on clinical judgment.
Advanced Diagnostics: Radiography is not routinely recommended in the absence of red flags or other specific individual factors (e.g., potential contraindications to treatment).

8. Diagnostic Criteria for Neck Pain Amenable to Conservative Care

A. Common Neck Pain (e.g., non-specific neck pain, mechanical cervicalgia, facet joint irritation, cervical strain/sprain, whiplash associated disorders (WAD) I-II, osteoarthritis, myofascial pain):

Pain: Arising below the nuchal line and above the cervicothoracic junction.
Signs/Symptoms: Sharp, dull, shooting, or aching pain; aggravated by specific movements; associated muscle stiffness or spasms; may include head, trunk or arm pain.
Exam: Pain reproduced by tests; no neurological deficits.

B. Neck Pain with Radicular Pain/Radiculopathy (from disc protrusion/herniation, foraminal stenosis, WAD III)

Pain: Neck pain radiating down the arm.
Signs/Symptoms: Sharp, shooting, or burning pain; numbness, tingling, weakness associated with a nerve root.
Exam: Positive tests (e.g., Spurling’s, Bakody, cervical distraction, upper limb tension tests); sensory deficits, muscle weakness, altered reflexes.

9. Treatment Considerations for Neck Pain Amenable to Conservative Care

(Common neck pain, pain with radicular pain/radiculopathy from disc pathology and WAD III)

After providing a report of findings and obtaining written informed consent.

Essential Interventions:
- Education and reassurance
- Encouragement to maintain activities of daily living
- Address yellow flags (psychosocial factors)
- Self-care (exercise, nutrition, sleep, stress management, healthy body weight, no smoking/substance abuse)
- Engage in social and work activities

Optional Interventions (with Rationale and Shared Decision Making):
- Exercise therapy
- Manual therapy (e.g., spinal manipulation/mobilization, soft tissue techniques, clinical or relaxation massage)
- Electrotherapies (e.g., low-level laser therapy)
- Medications (e.g., acetaminophen, ibuprofen/prescription). Discuss options/risks with medical provider.
- Psychological or social support
- Mind-body interventions (e.g., mindfulness, meditation)
- Needling therapies
- Multicomponent biopsychosocial care (e.g., exercise therapy, cognitive behavioural therapy, structured education and social support)

10. Prognosis

Recovery: Most people recover, but neck can recur or persist.
Negative Prognostic Factors: Smoking, obesity, higher initial pain and disability levels, poor recovery expectations, mental health issues, arm pain, work-related factors, previous neck pain.

11. Ongoing Follow-up

Continuously realign treatment plan with patient’s evolving goals, feedback, outcomes, and clinical judgement.
Consider referral or co-management if no improvement within established timeline for treatment (e.g., 6-8 weeks).

12. Criteria for Discharge

Establish clear criteria for discharge (e.g., achieving initial goals, reaching a plateau, progressing signs and symptoms).
Discuss post-discharge plans, including self-management strategies and potential follow-ups.

References